Provider Demographics
NPI:1679584882
Name:NISENSON, ROY (PHD MDIV)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:NISENSON
Suffix:
Gender:M
Credentials:PHD MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6930
Mailing Address - Country:US
Mailing Address - Phone:203-497-8320
Mailing Address - Fax:
Practice Address - Street 1:28 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6930
Practice Address - Country:US
Practice Address - Phone:203-497-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00678103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
018704OtherHEALTHNET
ZS381OtherOXFORD
CT060000678CT05OtherANTHEM
108432OtherVALUE OPTIONS
CT060000678CT05OtherANTHEM